McDonald blames crisis on demographics, budgets, and legislative mandates.
SANTA CLARA, Calif. — The struggles veterans face in accessing healthcare are a harbinger for all American medicine, and the problem won’t be resolved without adequate funding, said Department of Veterans Affairs Secretary Robert McDonald.
“VA is the canary in the coal mine. We learn about the problems in American medicine before American medicine,” McDonald told a roomful of reporters at the annual conference of the Association of Health Care Journalists here on Friday.
McDonald joined the VA last summer in the wake of an exploding controversy. Earlier in 2014, staff at a Phoenix VA hospital were found to have falsified scheduling records in order to mask extended delays in appointments. Hundreds of veterans were waiting months for appointments and some deaths were blamed on the delays.
Since his confirmation, McDonald — formerly the CEO of Procter and Gamble — has tried to turn around the agency’s image as mired in bureaucracy and more responsive to administrative edicts than veterans’ economic and healthcare needs.
McDonald blamed last year’s failures in access primarily on the growth of the aging veteran population, specifically Vietnam veterans. He also cautioned that the agency hasn’t yet seen “peak demand” from the veterans of Middle Eastern wars.
“If we don’t get ready today for what could happen many years from now with Iraq and Afghanistan veterans, we’re going to have another crisis.”
The key to avoiding future problems is adequate funding now, said McDonald. “That’s why we’re requesting such a large budget increase.” The VA has asked Congress for a 7.5% increase in discretionary funding for its 2016 budget. In recent markups, the House Appropriations Committee cut $1.4 billion from the budget. This frustrated McDonald.
“I don’t create the demand. I don’t pass the laws to decide what benefits to give veterans, all I do is execute the laws,” he said.
This puts him in a difficult place, as the department must provide legislatively mandated benefits to all eligible veterans on a budget that isn’t necessarily tied to their numbers or needs.
Aging Veterans, Greater Needs
The number of veterans is declining but that population is also getting older, said McDonald. Since older people have more health issues, the number of claims and issues per claim has dramatically increased.
From 2009 to 2017, the number of claims is rising from 1 million to a projected 1.5 million, with the number of issues per claim doubling, he said.
Other factors creating strain on veterans health centers include: the number of veterans returning from Iraq and Afghanistan; new requirements to assess and treat exposure to Agent Orange during the Vietnam War; the lack of limits on the appeals process; and increased survival on the battlefield that leaves more veterans with severe disabilities.
The other major factor contributing to access problems is the lack of providers, McDonald said.
Since he was hired, the agency has signed on 970 doctors and 2,000 nurses. “But we need more,” he said.
Finding providers who want to work in rural areas can be difficult, he said.
“I get beat up for not getting a primary care physician in the northwest corner of Montana but it’s hard to get primary care physicians in the northwest corner of Montana.”
Roscoe Butler, MD, deputy director for healthcare for the Veterans Affairs and Rehabilitation, who spoke on an afternoon panel at the conference, noted that salary differences and the rigidity of the system sometimes impeded providers who might choose to work for the VA.
Even when pay isn’t a disincentive, “[t]hey still have to have a lifestyle and they still have to be able to take care of patients the way they want,” Butler said.
Responding to the assertion that some providers applying for VA jobs faced delays getting hired, Butler was frank. “It’s absolutely true. Our hiring process is way too slow,” he said.
A primary care physician in good standing could get hired in a few days. So if the the VA takes 8 months to hire a provider, as some reporters suggested, he or she would certainly be swept up by other competitors.
Crunched for Space
McDonald said the agency also needs more money for construction, a budget he says has been underfunded for years. A majority of VA facilities are more than 50 years old, he noted; some only have bathrooms for men, even though more than 10% of veterans today are female.
In his visit to Phoenix just after being hired, McDonald found that, in addition to hospitals there being short 1,000 providers, doctors lacked space to care for patients. While the common standard for adequate clinical space is three clinical rooms per doctor, physicians in Phoenix had only one room each.
While supporting building new sites and expanding current centers, McDonald stressed that he believes in the Veterans Choice Act — a law which allows veterans who are more than 40 miles from a VA facility to receive care at a community health center. He’s working to ensure that the legislation reinterprets the definition of 40 miles to miles in driving distance. He estimates this change would double the number of veterans able to access care in community centers.
“Despite what you may have heard, we’re very much in favor of community care. We think the system of the future will be a VA system with a VA nucleus and a community care system that surrounds it.”
In addition to trying to explain the agency’s difficulties, McDonald lauded its improvements: now 97% of appointments happen within 30 days of the veteran’s preferred date, and 20% have been walk-ins. He noted that there have been 2.6 million new authorizations for veterans to access care in the private sector from May 2014 through March 2015 — a 44% increase from the previous year.
McDonald said the agency become more transparent, posting updates of their access on a bi- weekly basis. It is also seeking advice from companies like Starbucks and the Ritz Carlton to build better relations with veterans.
At the journalists’ conference, McDonald also announced formation of a special medical advisory group consisting of physicians, other providers, and former health system executives to create a “Blueprint for Excellence” for improving VA performance.
“Just like any good business, we have to reinvent ourselves,” said McDonald.